Documentation of care is essential for professional communication and good patient management and has presented a challenge over time for most health professions. For registered dietitian nutritionists (RDNs), the use of the Nutrition Care Process (NCP) and Nutrition Care Process Terminology (NCPT)1 offers a structured approach to documentation. However, the increasing use of electronic health records (EHRs), the emphasis on evidence-based practice, funding pressures, and the expectations for efficiencies in time management has placed additional demands on the delivery of nutrition care.
